Background. Studies around the world have documented that one-quarter or more of patients with type 2 diabetes (T2D) are highly reluctant to initiate basal insulin when recommended, often leading to extended periods of hyperglycemia. The critical causes underlying this phenomenon, commonly referred to as “psychological insulin resistance” (PIR), have been well described (e.g., injection anxiety), but little is known about how PIR can be overcome. 

Aims. To address this research gap, we developed the EMOTION study (AccEpting Insulin TreatMent for Reluctant PeOple with Type 2 DIabetes Mellitus – A GlObal Study to IdeNtify Effective Strategies). We surveyed T2D adults from seven countries who reported experiencing PIR in the past but who eventually began using basal insulin and are current insulin users. Our goal was to identify key healthcare providers’ (HCPs) actions and/or other life events that influenced these initially reluctant T2D patients to begin using insulin regularly. Given the absence of structured interventions for PIR, information gathered from these “PIR successes” may potentially be used to aid patients currently struggling with PIR to more easily transition to basal insulin use.  

Method. We utilized patient panels, relevant website announcements and referrals from local clinicians to identify and recruit patients in each of seven countries: Brazil, Canada, Germany, Japan, Spain, the United Kingdom, and the United States. Inclusion criteria were: age ≥21 years old, initiated basal insulin within the past 36 months, had T2D for ≥12 months before basal insulin initiation, indicated being reluctant to begin insulin therapy when it was first recommended, but now currently using insulin. Patients then completed a 30-minute online survey that included a newly-designed questionnaire (the PIR Solutions Questionnaire, or PSQ) aimed at identifying specific patient-reported events (e.g., HCP actions) that convinced them to begin basal insulin use. PSQ items were developed from 58 comprehensive patient and clinician recorded interviews in six of the seven countries, resulting in 45 items rated on a 5-point scale denoting whether the item occurred and level of helpfulness for initiating insulin use. Provisional analyses examined the level of helpfulness reflected by each of the 45 items. In exploratory factor analyses (EFA) we then examined underlying themes or subscales of helpfulness to successfully address PIR. 

Results. Survey data were collected from 459 respondents across the seven countries. HCP actions identified as most helpful for PIR success (% of sample identifying the action as helping at least moderately) included: having had one’s HCP walk through process of how to take insulin (75%), describing how blood glucose values would improve after insulin initiation (73%), and explaining that blood glucose values were not under good control (66%). In contrast, the least helpful HCP actions included: stating they would not continue to treat the patient unless the patient initiated insulin (22%), helping the patient meet other people who have been taking insulin (24%), warning the patient that HCP cannot be responsible for what may happen if the patient does not start insulin soon (27%). EFA results suggested a four factor solution of helpfulness, with item loadings conceptually representing the following areas (scale scores ranging from 1=”didn’t help at all”/didn’t occur to 4=”helped a lot”): Addressing Injection Concerns (e.g., “HCP walked me through the process of how to take insulin”; M=2.7, SD=0.8), Addressing Insulin Concerns (e.g., “HCP helped me recognize insulin would not cost as much as I feared”; M=2.2, SD=0.8), Collaborative Encouragement (e.g., “HCP took time to answer all my questions and address my concerns”; M=2.7, SD=0.7) and Authoritarian Encouragement (e.g., “HCP said that I needed to trust that they knew best”; M=1.8, SD=0.7).  

Discussion. Findings point to the the key factors that contribute to the successful initiation and maintenance of basal insulin among patients with PIR, and help to identify which interventions may be most effective. Overall, addressing patients’ insulin injection concerns and engaging in collaborative encouragement were reported to be the most helpful actions by HCPs, while authoritarian encouragement strategies were reported as the least helpful. The study provides the first evidence pointing to successful strategies for overcoming PIR, and is a critical step towards the design of effective intervention protocols and broader clinical recommendations for HCPs.

Identifying solutions to psychological insulin resistance: an international study